Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Abstract WP130: Unruptured Intracranial Aneurysm Treatment Score Fails for at Risk Patients Over 58 Years Old

Introduction: The Unruptured Intracranial Aneurysm Treatment Score (UIATS) weighs treatment versus observation risk, while the PHASES score estimates rupture risk. Certain clinical and radiographic features overlap between them whereas other features diverge. Thus management decisions may rely on conflicting information.

Objective: We sought to determine the UIATS for known aneurysmal subarachnoid hemorrhage (aSAH) patients, as if the aneurysms been detected prior to rupture, and to correlate this with their PHASES scores.

Methods: UIATS and PHASES scores were calculated for consecutive aSAH patients admitted to a regional stroke center between 1/2014 and 8/2018. A UIAT differential score was derived by subtracting the ‘observation’ from the ‘treatment’ score (a higher score favors treatment). Pro-treatment UIATS rates were calculated for the whole group and after excluding patients with non definitive scores of -3 to 3. These rates were also calculated for age-quartiles (<44, 45-58, 59-66, and >/=67 years). The relationship of age and PHASES scores with UIATS was assessed using logistic regression.

Results: Of 130 total patients, 121 (mean age 55 +/-15 years) had complete data, with median PHASES score of 5, concordant with their ultimate aSAH. Conversely, their median UIATS score was -1, and only in 54 (45%) did the score show balance (0) or favor treatment. Excluding those with UIATS -3 to 3, the number dropped to 18 (15%). Each unit increase in PHASES score was associated with 23% higher likelihood of pro-treatment UIATS (OR: 1.23, 95% CI: 1.05-1.44, p=0.009) indicating a degree of harmony. In contrast, although age>/=70 increases PHASES score, the odds of UIATS favoring treatment decreased by 5% with each year increase [OR: 0.95, 95% CI: 0.92-0.98, p=0.002]. When the four quartiles were analyzed, as age rose >58 years, the likelihood of pro-treatment UIATS fell (45-58 years, 63%; 59-66 years, 32%; >/=67 years, 0%). Results were comparable when analysis was repeated after excluding cases with UIATS - 3 -to 3.

Discussion: UIATS and PHASES scores help guide management discussions, but clinicians should assume caution with those>58 years, as UIATS is more likely to fail these patients, who may still be at greater natural history risk of aneurysmal rupture.

QT/QTc safety and efficacy evaluation of teneligliptin in Indian type 2 diabetes mellitus patients: the "thorough QT/QTc" study (Q-SET study)

Background: Newer therapies, such as dipeptidyl peptidase-IV inhibitors, are increasingly being used in the treatment of type 2 diabetes mellitus (T2DM). Teneligliptin, a DPP4 inhibitor, currently commonly used as monotherapy or as add-on therapy, was generally well tolerated in patients with T2DM during clinical trials. No AEs related to QT prolongation were detected with 40 mg/day of teneligliptin, but were seen at a supratherapeutic dose of 160 mg/day. Aims and objective: To evaluate the safety of teneligliptin in type 2 diabetes patients with respect to QTc prolongation. Methodology: This was an open-label, prospective, multi-centric trial conducted in patients with T2DM aged ≥18 to ≤65 years with a hemoglobin A1c (HbA1c) ≥7.0% and gliptin naïve. Teneligliptin 20 mg once a day was added to the standard treatment. The dose of teneligliptin was increased to 40 mg once a day if required, on the basis of glycemic parameters. Twelve-lead ECG was recorded at baseline and follow-up visits. The QTc was calculated by using the Bazett's formula (QTc=QT/√RR). Results: The mean QT interval at screening (Visit 1, Day 0, baseline ECG) was 0.33±0.07 seconds, while at visit 2 (Day 1, post 2 hours of Teneligliptin dosing) it was 0.32±0.04 seconds, at visit 3 (Day 15) it was 0.32±0.04 seconds, and at visit 4 (Day 90) it was 0.32±0.03 seconds. The mean QTc interval at baseline was 0.37±0.04 seconds, while at visit 2 it was 0.37±0.04 seconds, at visit 3 it was 0.37±0.03 seconds, and at visit 4 it was 0.37±0.03 seconds. There was a significant reduction in fasting blood glucose (P=0.002), postprandial blood glucose (P<0.001), and HbA1c (P<0.001) at the end of the 3 months as compared to baseline. Conclusion: Teneligliptin at a therapeutic dose of 20 mg/day or 40 mg/day improved glycemic parameters significantly and did not cause QT/QTc interval prolongation.

Pomona Large Vessel Occlusion Screening Tool for Prehospital and Emergency Room Settings

Background

Early identification of patients with acute ischemic strokes due to large vessel occlusions (LVO) is critical. We propose a simple risk score model to predict LVO.

Method

The proposed scale (Pomona Scale) ranges from 0 to 3 and includes 3 items: gaze deviation, expressive aphasia, and neglect. We reviewed a cohort of all acute stroke activation patients between February 2014 and January 2016. The predictive performance of the Pomona Scale was determined and compared with several National Institutes of Health Stroke Scale (NIHSS) cutoffs (≥4, ≥6, ≥8, and ≥10), the Los Angeles Motor Scale (LAMS), the Cincinnati Prehospital Stroke Severity (CPSS) scale, the Vision Aphasia and Neglect Scale (VAN), and the Prehospital Acute Stroke Severity Scale (PASS).

Results

LVO was detected in 94 of 776 acute stroke activations (12%). A Pomona Scale ≥2 had comparable accuracy to predict LVO as the VAN and CPSS scales and higher accuracy than Pomona Scale ≥1, LAMS, PASS, and NIHSS. A Pomona Scale ≥2 had an accuracy (area under the curve) of 0.79, a sensitivity of 0.86, a specificity of 0.70, a positive predictive value of 0.71, and a negative predictive value of 0.97 for the detection of LVO. We also found that the presence of either neglect or gaze deviation alone had comparable accuracy of 0.79 as Pomona Scale ≥2 to detect LVO.

Conclusion

The Pomona Scale is a simple and accurate scale to predict LVO. In addition, the presence of either gaze deviation or neglect also suggests the possibility of LVO.

Abstract WP21: Extracranial Carotid Revascularization May Have Higher Mortality Rate in Acute Stroke Intervention

Background: The endovascular management of acute extracranial carotid artery (EcCA) occlusion is unclear, as hypotension, a known phenomenon with carotid revascularization (CR), may exacerbate stroke symptoms. Most studiesinclude patients with tandem intracranial occlusions requiring thrombectomy, and even in those cases, there remains variability in regards to the order and manner of endovascular therapy (e.g. extra- vs intracranial revascularization first.

Objective: We sought to compare the clinical and radiographic differences in EcCA patients who did or did not undergo proximal CR.

Methods: We identified patients screened for possible intervention with acute EcCA occlusion from our prospective stroke database from 1/2014-8/2016and abstracted their demographic, clinical, and radiographic data. We compared differences between groups using chi-square analysis.

Results: Thirty-four patients had EcCA: (10, 29% sole EcCA; 24, 71% tandem occlusions; these included 19 of our 143 (13%) patients undergoing acute stroke intervention (16 with tandem lesions, 3 without). Nine of the 16 tandem occlusion patients underwent specific CR, whereas in four we were unable to cross the EcCA, and in 3 only targeted the intracranial occlusion. The mean age was 69±14 years among 19 males and 15 females, with no intergroup differences. Most (19, 56%) received IV tPA in the whole group as well as the CR subset (7, 58%), who were loaded with antiplatelet agents afterwards; 11 underwent stent placement and 1 angioplasty alone. Although there were trends towards higher baseline and discharge National Institutes of Health Stroke scale scores (NIHSSS) among the CR group (19 vs 16 and 21 vs 18) and median discharge modified Rankin scales (5 vs 4), these were not significant (p>0.05). There were 5 deaths in both groups. As a comparison to the rest of our thrombectomy cohort, there was no significant difference in discharge NIHSSS (11 vs 13) among patients undergoing CR though there proportionately more deaths (25, 18%, no CRvs 5, 42%, CR, p<0.05).

Conclusion: These data suggest that EcCA patients should be informed of possible greater risk of mortality during acute stroke intervention. Further analyses may better identify practice standards to improve outcomes in this population.

Abstract TP432: Ventriculostomy Placement Improves Outcome in Hunt and Hess Grade 3-5 Subarachnoid Hemorrhage Patients Irrespective of Hydrocephalus

Background: Cerebrospinal fluid diversion may be necessary in the acute period after subarachnoid hemorrhage (SAH) if patients develop hydrocephalus. Though there is an opinion that certain ‘severe grade’ patients, e.g. Hunt and Hess (HH) grades 3-5, should have external ventricular drain (EVD) placement, regardless of hydrocephalus, there is no firm data, leaving the decision up to the judgement of the evaluating clinical team.

Objective: We sought to measure changes in HH grades among grade 3-5 patients based on whether or not they had EVD placement.

Methods: We prospectively collect demographic, clinical, and radiographic data on our SAH patients since January 2014. We selected HH grades 3-5 patients and compared admission and discharge HH grades among groups of patients who underwent EVD placement or surgical decompression within the first 24 hours and those who did not, using chi square test.

Results: Among 54 total patients, there were 37 grades 3-5 patients (HH 3, n=26, 70.3%; HH 4, n=5, 13.5%; HH 5, n=6, 16.2%) in two groups: no EVD, n=22 (59.5%) and EVD, n=14 (37.8%, data unavailable for 1 patient). At discharge HH grades were: HH 1, n=10 (27%); HH 2, n=1 (2.7%); HH 3, n=10 (27%); HH 4, n=3 (8.1%); HH 5, n=1 (2.7%); dead, n=11 (29.7%); missing data, n=1. Mean age of 37 HH 3-5 patients was 58 years with no significant difference between the 2 groups. Hydrocephalus was seen in 11 of the 22 no EVD group and 13 of the 14 EVD group, p=0.007. Improvement in HH score between admission and discharge was seen in 10/14 EVD group, compared with 5/22 of the no EVD group, p=0.010. Worsening of HH score was found in 8/17 no EVD group (5 HH grade 5 patients excluded from this analysis), and 1 HH 4 patient (out of 14) in the EVD group, p=.014. Mortality occurred in 11/22 of the no EVD group (HH 3=5; HH 4-5=6) and 1/14 of the EVD group (HH 4, p=0.007).

Conclusion: While the presence of hydrocephalus could potentially be a determinant in the decision to place EVDs among HH grades 3-5 patients, clinical change in patients who did not have an EVD placed occurred independently of hydrocephalus. Improvement of HH grade was more frequent, while its worsening was less common, among patients who underwent EVD or surgery within the first 24 hours. Mortality of HH grade 3 patients may also be impacted with EVD placement.

Abstract TP211: Pediatric Age, but Not Treatment and Imaging Findings, Impacts Outcome in Contrast Induced Encephalopathy

Background: Contrast induced encephalopathy (CIE) following radiographic procedures, though a well-recognized complication, occurs sporadically enough that its diagnosis, prognosis, and treatment remain undefined and varied.

Objective: We sought to identify clinical and radiographic criteria as well as treatment experience vis a vis reported outcomes.

Methods: We identified case reports in PUBMED using search terms “contrast induced encephalopathy/neurotoxicity” from which we collected clinical and radiographic variables.

Results: Among 52 reports (total 79 patients, including our own unpublished 3 cases) the mean age was 60±16 years, with similar gender distribution. Multiple different contrast media were used (mean dose, 207 ±158 mL). Onset was typically immediate, though delayed cases up to 39 days later occurred. There were 3 confirmed cases (n=2, direct evidence of contrast in cerebrospinal fluid; n=1, autopsy excluded other cause of abnormality) which we classified as ‘definite CIE’. No imaging hallmark features were described in 30 patients, whom we classified as ‘possible CIE.’ The remaining 47, ‘probable CIE,’ demonstrated either diffuse edema or enhancement, with the latter being a more common finding (enhancement=33, 42% vs 11, 14%). Administered treatments included: hydration (n=31), steroids (n=10), hyperosmolar agents (n=4), anti-hypertensives (n=3), anti-convulsants (n=3), thrombolytics (n=3), hemodialysis (n=2), hemicraniectomy (n=1), and n-acetylcysteine. (n=1). There was no correlation between imaging features nor treatment modality and final outcome. Resolution occurred within 5 ±9 days. While most patients improved, 9 (11%) had no/incomplete improvement including 2 (2.5%) who expired. The 2 fatal cases occurred among the only 2 children in the entire series, p<0.001.

Conclusion: The diagnostic approach to CIE may be systemized based on the identification of hallmark radiologic findings, which, whether present or absent, do not appear to affect outcome. Though hydration and supportive remedies are most common, other treatments were not associated with hastened or worsened symptom resolution. And while the outcome of CIE among adults is generally benign, it may be fatal in children.

Abstract T P20: Rate of Endovascular Ischemic Stroke Treatment Increases with Onsite Rather than Regional Capabilities

Introduction: Currently in the US, hospitals with Neuro-Interventional capabilities represent a small proportion of all acute care facilities, and most hospitals rely on regional transfers for these services. At the same time, it is known, that having to transfer patients for Neuro-interventional stroke therapy (NIST) decreases the rate of offering this therapy, because of the time lost in the transfer process.

Objective: We sought to compare the rates of NIST being offered to patients after the inception of these services on-site, compared with the prior calendar year.

Methods: All patients presenting with neurological disturbance within 4.5 hours with a National Institutes of Health Stroke score (NIHSSS) >/= 4 undergo emergent non contrast head computed tomography (CT) and CT angiography (CTA). All patients who have no contra-indications to systemic thrombolysis receive intravenous tissue plasminogen activator (IV tPA) and in addition, those with large vessel occlusion on CTA are offered NIST.

Results: A total of 333 patients were admitted with the diagnosis of ischemic stroke (IS) in 2013. Of these 15 (4.3%) patients were transferred for NIST of which 9 received IV tPA and 6 did not. In addition, 2 patients were declined for NIST by regional centers and 2 who were transferred were unable to undergo NIST due to CT changes upon transfer. In the calendar year 2014 to date (8.5 months), among 225 IS patients, 21 (9.3%) were offered NIST, including 1 patient who was transferred from a neighboring facility. All patients offered treatment, underwent treatment. Among the 21 patients, 1 had spontaneous recanalization, another had a distal stenosis but no occlusion, and in 3, the target lesion could not be reached for intervention due to proximal carotid occlusion. Among these patients the mean initial NIHSSS was 20 and mean NIHSSS at discharge was 10. No patients experienced symptomatic hemorrhage, and one patient expired due to malignant ischemic swelling.

Conclusion: Having on-site NI capabilities doubled our rate of offering NIST. Such data may factor into a hospital’s gap analysis as to its need for NIST. Further analysis is needed to assess whether our experience of significant decline in discharge NIHSSS corresponds to long-term good functional outcome.

Chromosomal rearrangements in lymphocytes of head and neck squamous cell carcinoma treated with chemotherapeutic agents

Squamous cell carcinoma especially of oral cavity is one of the most prevalent diseases in the world. Chromosomal rearrangements are known to play important role in the pathogenesis of many diseases including cancer. In case of Head and Neck Squamous Cell Carcinoma, chromosomal changes are detectable at all stages of tumor development providing excellent opportunity for chromosomal prognosis and therapy. The present work aimed to study the frequency and pattern of chromosomal aberrations in human peripheral blood lymphocyte culture of freshly diagnosed Head and Neck squamous cell carcinoma patients. Further In vitro anticancer drugs (5-Fluorouracil {5-FU } and Cisplatin) effects were studied for clastogenicity. Results indicated significant impact of chemotherapeutic agents on the frequency of different types of chromosomal rearrangements.

Stroke: working toward a prioritized world agenda

BACKGROUND AND PURPOSE

The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke.

METHODS

Preliminary work was performed by seven working groups of stroke leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants. The resulting draft document had further input from contributors outside the synergium.

RESULTS

Recommendations of the Synergium are: Basic Science, Drug Development and Technology: There is a need to develop: (1) New systems of working together to break down the prevalent 'silo' mentality; (2) New models of vertically integrated basic, clinical, and epidemiological disciplines; and (3) Efficient methods of identifying other relevant areas of science. Stroke Prevention: (1) Establish a global chronic disease prevention initiative with stroke as a major focus. (2) Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function. (3) Develop, implement and evaluate a population approach for stroke prevention. (4) Develop public health communication strategies using traditional and novel (eg, social media/marketing) techniques. Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks. Brain Recovery and Rehabilitation: (1) Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care. (2) Standardize poststroke rehabilitation based on best evidence. (3) Develop consensus on, then implementation of, standardized clinical and surrogate assessments. (4) Carry out rigorous clinical research to advance stroke recovery. Into the 21st Century: Web, Technology and Communications: (1) Work toward global unrestricted access to stroke-related information. (2) Build centralized electronic archives and registries. Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke care. Educate and energize professionals, patients, the public and policy makers by using a 'Brain Health' concept that enables promotion of preventive measures.

CONCLUSIONS

To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Advances can be made not only by doing, but ceasing to do. Significant savings in time, money, and effort could result from discontinuing practices driven by unsubstantiated opinion, unproven approaches, and financial gain. Systematic integration of knowledge into programs coupled with careful evaluation can speed the pace of progress.

Modelling asthma in macaques: longitudinal changes in cellular and molecular markers

The aim of the present study was to determine whether systemic sensitisation and chronic aeroallergen challenge in macaques replicate the classical and emerging immunology and molecular pathology of human asthma. Macaques were immunised and periodically challenged over 2 yrs with house dust mite allergen. At key time-points, serum, bronchoalveolar lavage (BAL) and bronchial biopsies were assayed for genes, proteins and lymphocyte subpopulations relevant to clinical asthma. Immunisation and periodic airway challenge induced changes in immunoglobulin E, airway physiology and eosinophilia consistent with chronic, dual-phase asthma. Sensitisation increased interleukin (IL)-1β and -6 concentrations in serum, and IL-13 expression in BAL cells. Airway challenge increased: early expression of IL-5, -6, -13 and -19, and eotaxin; and variable late-phase expression of IL-4, -5 and -13, and thymus- and activation-regulated chemokine in BAL cells. CD4+ lymphocytes comprised 30% of the CD3+ cells in BAL, increasing to 50% in the late phase. Natural killer T-cells represented <3% of the CD3+ cells. Corticosteroid treatment reduced serum histamine levels, percentage of CD4+ cells and monocyte-derived chemokine expression, while increasing CD3+ and CD8+ cells in BAL. Sensitisation and periodic aeroallergen challenge of cynomolgus macaques results in physiological, cellular, molecular and protein phenotypes, and therapeutic responses observed in human asthma, providing a model system useful in target and biomarker discovery, and translational asthma research.

Stroke: working toward a prioritized world agenda

BACKGROUND AND PURPOSE

The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke.

METHODS

Preliminary work was performed by 7 working groups of stroke leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants. The resulting draft document had further input from contributors outside the synergium.

RESULTS

Recommendations of the Synergium are: Basic Science, Drug Development and Technology: There is a need to develop: (1) New systems of working together to break down the prevalent "silo" mentality; (2) New models of vertically integrated basic, clinical, and epidemiological disciplines; and (3) Efficient methods of identifying other relevant areas of science. Stroke Prevention: (1) Establish a global chronic disease prevention initiative with stroke as a major focus. (2) Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function. (3) Develop, implement and evaluate a population approach for stroke prevention. (4) Develop public health communication strategies using traditional and novel (eg, social media/marketing) techniques. Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks. Brain Recovery and Rehabilitation: (1) Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care. (2) Standardize poststroke rehabilitation based on best evidence. (3) Develop consensus on, then implementation of, standardized clinical and surrogate assessments. (4) Carry out rigorous clinical research to advance stroke recovery. Into the 21st Century: Web, Technology and Communications: (1) Work toward global unrestricted access to stroke-related information. (2) Build centralized electronic archives and registries. Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke care. Educate and energize professionals, patients, the public and policy makers by using a "Brain Health" concept that enables promotion of preventive measures.

CONCLUSIONS

To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Advances can be made not only by doing, but ceasing to do. Significant savings in time, money, and effort could result from discontinuing practices driven by unsubstantiated opinion, unproven approaches, and financial gain. Systematic integration of knowledge into programs coupled with careful evaluation can speed the pace of progress.

Stroke: working toward a prioritized world agenda

BACKGROUND AND PURPOSE

The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke.

METHODS

Preliminary work was performed by 7 working groups of stroke leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants. The resulting draft document had further input from contributors outside the synergium.

RESULTS

Recommendations of the Synergium are: Basic Science, Drug Development and Technology: There is a need to develop: (1) New systems of working together to break down the prevalent 'silo' mentality; (2) New models of vertically integrated basic, clinical, and epidemiological disciplines; and (3) Efficient methods of identifying other relevant areas of science. Stroke Prevention: (1) Establish a global chronic disease prevention initiative with stroke as a major focus. (2) Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function. (3) Develop, implement and evaluate a population approach for stroke prevention. (4) Develop public health communication strategies using traditional and novel (e.g., social media/marketing) techniques. Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks. Brain Recovery and Rehabilitation: (1) Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care. (2) Standardize poststroke rehabilitation based on best evidence. (3) Develop consensus on, then implementation of, standardized clinical and surrogate assessments. (4) Carry out rigorous clinical research to advance stroke recovery. Into the 21st Century: Web, Technology and Communications: (1) Work toward global unrestricted access to stroke-related information. (2) Build centralized electronic archives and registries. Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke care. Educate and energize professionals, patients, the public and policy makers by using a 'Brain Health' concept that enables promotion of preventive measures.

CONCLUSIONS

To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Advances can be made not only by doing, but ceasing to do. Significant savings in time, money, and effort could result from discontinuing practices driven by unsubstantiated opinion, unproven approaches, and financial gain. Systematic integration of knowledge into programs coupled with careful evaluation can speed the pace of progress.

Characterization of the expression of variant and standard CD44 in prostate cancer cells: identification of the possible molecular mechanism of CD44/MMP9 complex formation on the cell surface

CD44 is a glycosylated adhesion molecule and osteopontin is one of its ligand. CD44 undergoes alternative splicing to produce variant isoforms. Our recent studies have shown an increase in the surface expression of CD44 isoforms (sCD44 and v4-v10 variant CD44) in prostate cancer cells over-expressing osteopontin (PC3/OPN). Formation of CD44/MMP9 complex on the cell surface is indispensable for MMP9 activity. In this study, we have characterized the expression of variant CD44 using RT-PCR, surface labeling with NHS-biotin, and immunoblotting. Expression of variant CD44 encompassing v4-v10 and sCD44 at mRNA and protein levels are of the same levels in PC3 and PC3/OPN cells. However, an increase in the surface expression of v6, v10, and sCD44 in PC3/OPN cells suggest that OPN may be a ligand for these isoforms. We then proceeded to determine the role of sCD44 in MMP9 activation. Based on our previous studies in osteoclasts, we hypothesized that phosphorylation of CD44 has a role on its surface expression and subsequent activation of MMP9. We have prepared TAT-fused CD44 peptides comprising unphosphorylated and constitutively phosphorylated serine residues at positions Ser323 and Ser325. Transduction of phosphopeptides at Ser323 and Ser323/325 into PC3 cells reduced the surface levels of CD44, MMP9 activity, and cell migration; but had no effect on the membrane localization of MMP9. However, MMP9 knock-down PC3 cells showed reduced CD44 at cellular and surface levels. Thus we conclude that surface expression of CD44 and activation of MMP9 on the cell surface are interdependent.

Choosing pacemakers appropriately

The range of implantable cardiac pacing devices has expanded, with the advances in available technology. Indications for cardiac pacing devices, that is pacemakers, implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy devices (CRTs), have expanded for the treatment, diagnosis and monitoring of bradycardia, tachycardia and heart failure. While the need for pacemakers is increasing, not all patients who require pacemakers are receiving them, especially in the Asia-Pacific region. There is a need to be more critical in advising the use of more expensive devices like ICDs and CRT/CRT-D devices, since most patients in the Asia-Pacific region pay out of pocket for these therapies. The AHA-ACC guidelines need not be blindly followed, since they are too wide-sweeping and are often based on the intention-to-treat basis of trials rather than on the parameters of the patients actually enrolled.

Circadian function in patients with advanced non-small-cell lung cancer

This study aimed to evaluate whether patients with advanced non-small-cell lung cancer experience disrupted rest–activity daily rhythms, poor sleep quality, weakness, and maintain attributes that are linked to circadian function such as fatigue. This report describes the rest–activity patterns of 33 non-small-cell lung cancer patients who participated in a randomised clinical trial evaluating the benefits of melatonin. Data are reported on circadian function, health-related quality of life (QoL), subjective sleep quality, and anxiety/depression levels prior to randomisation and treatment. Actigraphy data, an objective measure of circadian function, demonstrated that patients' rest–activity circadian function differs significantly from control subjects. Our patients reported poor sleep quality and high levels of fatigue. Ferrans and Powers QoL Index instrument found a high level of dissatisfaction with health-related QoL. Data from the European Organization for Research and Treatment for Cancer reported poor capacity to fulfil the activities of daily living. Patients studied in the hospital during or near chemotherapy had significantly more abnormal circadian function than those studied in the ambulatory setting. Our data indicate that measurement of circadian sleep/activity dynamics should be accomplished in the outpatient/home setting for a minimum of 4–7 circadian cycles to assure that they are most representative of the patients' true condition. We conclude that the daily sleep/activity patterns of patients with advanced lung cancer are disturbed. These are accompanied by marked disruption of QoL and function. These data argue for investigating how much of this poor functioning and QoL are actually caused by this circadian disruption, and, whether behavioural, light-based, and or pharmacologic strategies to correct the circadian/sleep activity patterns can improve function and QoL.

Maternal activity in relation to birth size in rural India. The Pune Maternal Nutrition Study

OBJECTIVE

To describe the relationship of the mother's physical activity to the birth size of her baby in a rural Indian population.

DESIGN

: Prospective observational study.

SETTING

Six villages near Pune, Maharashtra, India.

SUBJECTS

: A total of 797 women were studied after excluding abortions and termination of pregnancies (112), foetal anomalies (8), multiple pregnancies (3), incomplete pre-pregnancy anthropometry (14) and pregnancies detected later than 21 weeks of gestation (168).

METHOD

An activity questionnaire was developed after focus group discussions and incorporated community-specific activities. It was validated against an observer-maintained diary. Activity scores were derived using published data on energy costs to weight the contributions of various activities. It was then administered to assess physical activity at 18 (+/-2) and 28 (+/-2) weeks of gestation.

OUTCOME MEASURES

Birth outcome, maternal weight gain and neonatal anthropometry.

RESULTS

The activity questionnaire was used to classify women into light, moderate and heavy activity categories. Maternal activity did not influence the incidence of prematurity or stillbirth, or the duration of gestation. It was inversely related to maternal weight gain up to 28 weeks of gestation (P=0.002). Higher maternal activity in early, as well as mid gestation, was associated with lower mean birth weight (P=0.05 and 0.02, respectively ), and smaller neonatal head circumference (P=0.005 and 0.009) and mid-arm circumference (P=0.03 and 0.01) after adjusting for the effect of major confounding factors.

CONCLUSIONS

The Findings suggest that excessive maternal activity during pregnancy is associated with smaller foetal size in rural India, The approach described for developing an activity questionnaire has potential for adoption in other settings.

Evaluation of the role of lipoprotein metabolism genes in systemic cationic liposome-mediated gene transfer in vivo

Germ line gene disruption and gene insertion are often used to study the function of selected genes in vivo. We used selected knockout and transgenic mouse models to attempt to identify lipoprotein-related genes and gene products that regulate the process of intravenous cationic liposome-DNA complex (CLDC)-based gene delivery. Several observations suggested that proteins involved in lipoprotein metabolism might be important in influencing the delivery and/or expression of CLDC. First, in vitro transfection of either K562 or CHO cells by CLDCs was enhanced by the presence of a functional low-density lipoprotein receptor (LDLR). Second, pretreatment of mice with 4-aminopyrazolopyrimidine (4APP), an agent that alters lipoprotein profiles in mice, significantly decreased expression of luciferase (luc) after intravenous injection of CLDC-luc complexes in mice. Therefore, we tested mouse model systems either deficient for, or overexpressing, selected genes involved in lipoprotein metabolism, for their potential to regulate intravenous, CLDC-based gene delivery. Although homozygous knockout mutation in the apoE gene caused a significant decrease in gene expression in many tissues of apoE-deficient mice, mice with homozygous deletion of both the apoE and LDLR genes showed wild-type levels of gene transfer efficiency. Thus, a secondary event, produced by homozygous deletion of apoE, but compensated for by the concomitant deletion of LDLR, and/or effects resulting from strain-related, genetic background differences, appeared to play a significant role in mediating intravenous, CLDC-based gene delivery. Secondary alterations resulting from germ line knockouts, as well as epigenetic effects produced by strain differences, may limit the ability to assign specific, gene transfer-related functions to the deleted gene.

Synthesis and QSAR studies of 4-substituted phenyl-2,6-dimethyl-3, 5-bis-N-(substituted phenyl)carbamoyl-1,4-dihydropyridines as potential antitubercular agents

Synthesis and QSAR studies of the title compounds have resulted in the identification of structural and physicochemical parameters (MR, sigma(o), sigma(m), sigma(p)) contributing to antitubercular activity. Among these, carbamoyl phenyl ring substituted at 3 and 4 position with NO(2) group or 2 position with Cl or OCH(3) group shows >90% inhibition against H(37)Rnu comparable to other substituted phenyls.

Piperidinium 3-[(4-hydroxy-5-dimethyl-2-oxo-2H-chromen-3-yl)-phenylmethyl]-5,7-dimethyl-2-oxo-2H-chromen-4-olate

In the title salt, C5H12N+*C29H23O6-, both benzopyran systems are planar. Intermolecular N--H...O hydrogen bonds and a short O--H...O intramolecular hydrogen bond are observed in the structure.

The utility of routine electrolytes and blood cell counts in patients with chest pain

The objective of the study was to determine whether the routine screening laboratory tests, electrolytes (E) and hemoglobin and hematocrits (H/H), could have been safely avoided in ED patients presenting with chest pain. Retrospective case series over a 3-month period were reviewed. Acceptable indications for E and H/H test ordering were prospectively developed using American College of Emergency Physicians (ACEP) guidelines. Charts were reviewed to determine whether any indications were present, whether the E and H/H laboratory tests were abnormal, and whether the abnormal test affected treatment or disposition. Patients were excluded if they had an abnormal electrocardiogram (ECG) indicating ischemia or electrolyte abnormality. This resulted in 191 patients meeting inclusion criteria. Sixty-eight patients did not have any criteria for ordering E or H/H. Of these, only one (1.5%) had an abnormal laboratory test. The sensitivity of the guidelines for predicting an abnormal laboratory test was 96% (95 CI, 82 to 100%) and the specificity was 46% (95CI, 38 to 54%). There were no interventions, consultations, or any change in disposition based on E or H/H testing in these patients. Of the 123 patients that met at least one criteria for ordering laboratory tests, 27 (18%) had an abnormal result. It was concluded that practice guidelines may reduce the number of E and H/H tests ordered without missing significant abnormalities. A prospective trial is needed to validate these findings.

Intake of micronutrient-rich foods in rural Indian mothers is associated with the size of their babies at birth: Pune Maternal Nutrition Study

One third of the Indian babies are of low birth weight (<2.5 kg), and this is attributed to maternal undernutrition. We therefore examined the relationship between maternal nutrition and birth size in a prospective study of 797 rural Indian women, focusing on macronutrient intakes, dietary quality and micronutrient status. Maternal intakes (24-h recall and food frequency questionnaire) and erythrocyte folate, serum ferritin and vitamin C concentrations were measured at 18 +/- 2 and 28 +/- 2 wk gestation. Mothers were short (151.9 +/- 5.1 cm) and underweight (41.7 +/- 5.1 kg) and had low energy and protein intakes at 18 wk (7.4 +/- 2.1 MJ and 45.4 +/- 14.1 g) and 28 wk (7.0 +/- 2.0 MJ and 43.5 +/- 13.5 g) of gestation. Mean birth weight and length of term babies were also low (2665 +/- 358 g and 47.8 +/- 2.0 cm, respectively). Energy and protein intakes were not associated with birth size, but higher fat intake at wk 18 was associated with neonatal length (P < 0.001), birth weight (P < 0.05) and triceps skinfold thickness (P < 0.05) when adjusted for sex, parity and gestation. However, birth size was strongly associated with the consumption of milk at wk 18 (P < 0.05) and of green leafy vegetables (P < 0.001) and fruits (P < 0.01) at wk 28 of gestation even after adjustment for potentially confounding variables. Erythrocyte folate at 28 wk gestation was positively associated with birth weight (P < 0.001). The lack of association between size at birth and maternal energy and protein intake but strong associations with folate status and with intakes of foods rich in micronutrients suggest that micronutrients may be important limiting factors for fetal growth in this undernourished community.

Direct extracellular contact between integrin alpha(3)beta(1) and TM4SF protein CD151

Previously we established that the alpha(3)beta(1) integrin shows stable, specific, and stoichiometric association with the TM4SF (tetraspannin) protein CD151. Here we used a membrane impermeable cross-linking agent to show a direct association between extracellular domains of alpha(3)beta(1) and CD151. The alpha(3)beta(1)-CD151 association site was then mapped using chimeric alpha(6)/alpha(3) integrins and CD151/NAG2 TM4SF proteins. Complex formation required an extracellular alpha(3) site (amino acids (aa) 570-705) not previously known to be involved in specific integrin contacts with other proteins and a region (aa 186-217) within the large extracellular loop of CD151. Notably, the anti-CD151 monoclonal antibody TS151r binding epitope, previously implicated in alpha(3) integrin association, was mapped to the same region of CD151 (aa 186-217). Finally, we demonstrated that both NH(2)- and COOH-terminal domains of CD151 are located on the inside of the plasma membrane, thus confirming a long suspected model of TM4SF protein topology.

Human intervertebral disc cells from the annulus: three-dimensional culture in agarose or alginate and responsiveness to TGF-beta1

Cell culture procedures were developed for use with surgical and normal control specimens of the annulus of the human intervertebral disc. Cells were established in monolayer explant culture and seeded into three-dimensional growth environments of alginate or agarose; under these growth conditions cells assumed a rounded phenotype and formed colonies. A novel method of layering suspensions of cells onto cell well inserts proved technically much easier than the microbead culture method. Immunohistochemistry was utilized to demonstrate in vitro production of the following extracellular matrix components: types I, II, III, and VI collagen, 4-S-chondroitin sulfate, and keratan sulfate. Young and old age- and gender-matched cells grown in the presence of TGF-beta1 showed significant enhancement of proliferation after 4 days of exposure to TGF-beta with a lessened mitogenic response present after 10 days. Molecular studies of proteoglycan gene expression showed that at 4 days young normal cells had increased biglycan, but not decorin, message levels. Decorin expression was unchanged at Day 4 and decreased or shut off by Day 10. Results support the use of three-dimensional culture systems for in vitro evaluation of human disc cell function and expand our understanding of the in vitro behavior of these cells.